Safety and efficacy of early extubation of elderly coronary artery bypass surgery patients.

OBJECTIVE: Early extubation and fast-track management protocols on younger, low-risk patients result in shorter hospital stays and decreased costs. The impact of such protocols on elderly patients undergoing coronary artery bypass graft (CABG) surgery is not presently known. DESIGN: A matched retrospective cohort study. SETTING: A university teaching hospital. PARTICIPANTS: Six hundred ninety-eight consecutive patients undergoing isolated CABG between January 1995 and September 1996. INTERVENTIONS: Three hundred seventy-seven patients underwent early extubation, defined as extubation within 8 hours of arrival in the intensive care unit. They were divided into groups of patients 70 years of age and younger (n = 263) and patients older than 70 years of age (n = 114). RESULTS: The mean length of stay (LOS) for all patients extubated within 8 hours or less was 5.5 days versus 8.4 days for patients who underwent later extubation (p < 0.0001). The percentage of patients undergoing early extubation was greater for the younger cohort (59% v 48%; p < 0.003) compared with the older cohort of patients. Analysis of demographics showed the older patients to have a greater incidence of peripheral vascular disease, congestive heart failure, and prior strokes (p < 0.05). Although the intensive care unit LOS was similar, postoperative LOS was 5.3 +/- 1.8 days for the younger patients versus 6.1 +/- 2.6 days for the older patients (p = 0.001). The overall surgical mortality rate was 2.6% (18/698), and there were no deaths among patients undergoing early extubation. Reintubation rate was negligible in both groups of patients. CONCLUSION: This study confirms the safety and efficacy of early extubation among elderly patients undergoing CABG. Elderly patients have more comorbid conditions, yet a significant number can be extubated early, with resultant shortened LOSs.

How to transfer a postoperative patient to the intensive care unit. Strategies for documentation, evaluation, and management.

Postoperative intensive care is often required for patients who have underlying cardiac or respiratory dysfunction, who undergo major surgery, or who experience major perioperative complications. The initial report should list the patient's intravenous lines, catheters, and surgical drains or tubes, as well as whether ventilation is needed; this allows the intensive care unit (ICU) staff to set up appropriate equipment. On the patient's arrival in the ICU, document the medical history, anesthetics given, surgery performed, and intraoperative events. Perform an organ system review with ongoing assessment at 15-minute intervals. Residual effects of anesthetic agents can include respiratory depression, hypotension, and bradycardia.

Unilateral auto-PEEP in the recipient of a single lung transplant.

We report a patient who received a right single lung transplant (SLT) for progressive lymphangioleiomyomatosis and required reintubation for postoperative respiratory distress. She developed hemodynamic instability due to mediastinal shift from unilateral auto-PEEP with hyperinflation of the native lung. Placement of a double lumen endotracheal tube (DLET) and institution of differential lung ventilation restored equal lung inflation and hemodynamic stability.